Role and Methodologies

Education and service (e.g., consultation and policy formation) are the foci of clinical ethics efforts in most healthcare institutions. Typically, a clinical ethics program in a healthcare institution, such as a large hospital, will provide staff and community education, policy critique and formulation, retrospective and prospective case review, and case consultation. The most active clinical ethics programs tend to be at academic medical centers that employ clinical ethicists. In the academic medical setting, clinical ethicists may be involved in teaching at all levels of health-professional education (preclinical, clinical, graduate, postgraduate, and continuing education). Some institutions with programs in clinical ethics offer advanced education and training through fellowship or degree programs. They may also have outreach efforts to assist in the formation of clinical ethics programs and the training of leaders for these programs.

Although education and service are central to any clinical ethics program, research can be an important component as well, particularly in an academic setting. Such research may include the type of conceptual and analytic work characteristic of humanities research (e.g., case analysis, conceptual clarification, normative assessment of particular clinical ethics issues) or the type of empirical research more characteristic of the social sciences (e.g., frequency occurrence of various ethical problems; the practical impact of various policies or practices; attitudes and beliefs of specific populations toward particular ethical issues; effectiveness of certain interventions designed to promote informed consent, protect privacy, and so forth) (Singer, Siegler, and Pellegrino). The increasingly vast clinical ethics literature is indicative of the dramatic growth in clinical ethics research since the 1980s.

Like clinical ethics itself, discussions of methodological issues in clinical ethics have evolved and developed over the years. As clinical ethics emerged, the prevailing approach to bioethical inquiry (Beauchamp and Childress) used systematic reflection on moral principles and their relevance for resolving ethical problems in biomedicine by weighing and balancing the claims of competing principles (an approach known as principlism). Although this mainstream approach achieved valuable work, criticisms pointed to three ways in which the approach needed to be strengthened: (1) more attention needed to be given to the nature of diseases and the clinical contexts in which clinicians and patients face ethical problems (Sider and Clements); (2) the criticism that principlism appeared to promote a hierarchical form of reasoning that deduced ethical resolutions for complex clinical problems from fixed moral principles and rules needed to be addressed (Jonsen and Toulmin); and (3) in addition to moral principles, more conceptual and methodological resources for ethical inquiry needed to be developed, because principlism appeared too vague and flexible to yield well-reasoned conclusions (Clouser and Gert).

In response to these perceived inadequacies in the forms of ethical inquiry, Glenn C. Graber and David C. Thomasma attempted to recast the theory and practice of medical ethics in terms of a "unitary ethical theory" founded in clinical medicine itself (Ackerman et al.). Their contribution, with strengths and weaknesses, was expertly reviewed in 1990 by Richard M. Zaner, a philosopher with significant clinical experience, who enriched the literature with narratives of illness and of the ethical conflicts over uses of high technology that are frequent in tertiary-care centers. Other contributors to the clinical ethics literature responded by drawing on the works of feminist (Gilligan; Noddings; Wolf; Tong) and theological (Hauerwas) writers who criticized bioethics for neglecting the ethical significance of specific clinical virtues, such as caring for persons in concrete human relationships.

Additional methodological resources for ethical inquiry appeared in the renewal of interest in casuistry, the art of ethical analysis that compares and contrasts relevantly similar cases (Jonsen and Toulmin; Brody, 1988; Arras). Clinical decision making is case-specific: It is directed at the care of a particular patient faced with a particular illness or injury. Each case has a history: what preceded the problems that needed medical attention, what needed to be done, and what was done to address the problems presented by the patient. Because it focuses on the ethics of clinical practice, clinical ethics strives for the richest possible descriptions of cases and their interpersonal dynamics and power differentials. In this vein, several anthologies of cases have appeared with well-informed clinical discussions (Pence; Crigger), including casebooks with cases drawn from ethics consultations (Kuczewski and Pinkus; Culver). Like the practice of clinical medicine, casuistry builds on the accumulated experience, both of the individual and of the professions, in dealing with a variety of cases. Comparing and contrasting related cases can reveal important ethical considerations that may not be apparent in isolated focus on a particular case.

Yet another response to critiques of earlier bioethics was to deepen and enrich the study of larger issues and themes in clinical practice, both by using cases and by drawing on knowledge available only through the intimacies of the clinician—patient encounter. Authors of such studies tend to be clinician-ethicists or ethicists who have adapted to the clinical setting sufficiently to share in such intimacies. Four examples among many are discussions of informed consent (Katz), life-and-death decision making (Brody, 1988), pain and suffering (Cassell), and the uses of power by clinicians (Brody, 1992). These studies draw on a variety of disciplines and experiential data obtained in clinical settings. As such, they encourage ethical scrutiny and reform of understandings and practices in the clinical encounters between patients and clinicians (Zaner). In this way, clinical ethics strengthens the conceptual underpinnings of bioethics with experiential data and helps motivate clinicians to reform their practices.

The continuing multidisciplinary growth in clinical ethics has, not surprisingly, created a great deal of methodological diversity in approaching clinical ethics issues. Methodological approaches characteristic of various health professions, the humanities, and the social sciences can be found in the literature (McGee; Charon and Montello; Kuczewski; Nelson; Bosk; Moreno). In practice, the approaches of different persons involved in clinical ethics efforts will, naturally, reflect, at least in part, their professional or disciplinary perspective. This is part of the great richness of clinical ethics.

In the face of this rich methodological diversity, clinical ethics, far from being fragmented, is held together by a profoundly practical aim: to make contributions to clinical practice and to policy governing clinical practice. To the extent that it is able to achieve this, clinical ethics must pay careful attention to and take into account certain features of the clinical context. As mentioned at the outset, these features include complex psychosocial, medical, legal, cultural, and political dimensions that have implications both for the types of ethical issues that arise and how these issues may be resolved (Society for Health and Human Values). For example, in the United States, the pluralistic societal context, the rights of individuals to live according to their values, and the value-laden nature of clinical practice make ethical conflict or uncertainty an inevitable feature of the clinical setting. Indeed, these features, in conjunction with advances in medical technology, arguably have created the need for formal efforts in clinical ethics. In the U.S. societal context, therefore, irrespective of the methodological approach employed by any particular person in working to address a given clinical ethics issue, the political rights of individuals must be taken into account if the approach is to make a contribution to actual clinical practice. Thus, in a very real sense, methodological approaches in clinical ethics and the theoretical commitments behind them are subordinated to the practical aim of this discipline.